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Painful Indurated Plaques on the Vulva

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 60s presented with a painful skin eruption on the vulva of 2 months’ duration. The patient had a history of rectal carcinoma with lymph node metastasis and 2 years prior had received low anterior resection plus postoperative chemotherapy (6 cycles of oxaliplatin, calcium folinate, and tegafur). A physical examination revealed well-defined, firm, indurated plaques on the vulva with nodules on the surface (Figure 1A). A biopsy of the left vulva was performed (Figure 1B and C).

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D. Cutaneous metastatic mucinous carcinoma from rectal carcinoma

Histopathologic examination findings revealed irregular islands of tumor cells with a cribriform morphology floating in large mucin pools that were separated by thin fibrous septae. Immunohistochemical analysis showed the tumor cells to be positive for cytokeratin (CK) 20 (Figure 2) and negative for CK7. Serum carcinoembryonic antigen and carbohydrate antigen 199 levels were 73.77 ng/mL (normal range, 0-5.2 ng/mL) and 236.9 IU/mL (normal range, 0-39 IU/mL), respectively. Pelvic computed tomography results revealed inguinal and retroperitoneal lymphadenopathy. Findings from the thoracic computed tomography scan were normal. The medical history, and histopathological and immunohistochemical findings suggested a diagnosis of cutaneous metastatic mucinous carcinoma from rectal carcinoma. The patient was referred to an oncologist and is presently undergoing radiotherapy.

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Article Information

Corresponding Author: Zhirong Yao, MD, Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Rd, Yangpu District, Shanghai 200092, China (yaozhirong@xinhuamed.com.cn).

Published Online: July 17, 2019. doi:10.1001/jamadermatol.2019.1979

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grants from the National Natural Science Foundation of China (81874252 and 81630083) and a grant from the Shanghai Sailing Program (16YF1407400).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient for granting permission to publish this information.

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